“old” antidepressant with multiple side effects and restrictions finally helped lift the cloud of depression. With the support of her psychiatrist, she stopped taking this antidepressant after she was in obvious remission. She continued to see the psychiatrist for “check ups” as needed. She was very sensitive to when the “darkness” came back. As she has aged into her 40’s, she has had multiple episodes of major depression and one episode of mild mania. She states most of the time she “lives right under the line of normal.” She describes depression and mania as physically painful. Her analogy is one of climbing out of a pool of dark tar on a stepladder. She really never gets out of the pool. Sometimes she has been up to her neck in tar; at other times, she has had both feet on the stepladder. Medication balance is critical since certain antidepressants may force Linda into a manic state. She has biweekly visits with her psychiatrist. She has been with him for nearly 15 years. She is very knowledgeable about her illness and is motivated to maintain her “normal” state instead of “being in the darkness.” Fear motivates her as well as her children and grandchildren. She actually says her children saved her life because she was severely suicidal but maintained for them. Her psychiatrist considers her a “very high functioning Bipolar.” Even with all that, Linda still has times of non-adherence. If certain life circumstances hit her, her psychiatrist may increase a dose of one of her medications. If she has headaches or sexual dysfunction, she will stop taking this increased dose. She says she knows her body and when she needs the increased dose of medication. Linda also says that only she has the ability to pull herself out of the tar and up the ladder. She says she works daily to stay on that ladder.

Case Study 4

Martin was diagnosed with diabetes nearly one year ago. He is a 65-year-old man living in Florida. Healthcare is very accessible, and Martin visits his primary care physician monthly to assess his “sugar diabetes.” The primary care physician assessed Martin via A1C levels and asked him about his diet, exercise, and medications. Martin was involved in a diabetes disease management process with his managed care organization. The care manager assigned to Martin had been phoning him for approximately six months. She was beginning to notice a change in Martin’s discussions with her and his general “attitude.” Whenever she would ask about maintenance of his diabetes, he would say, “It really doesn’t matter anyway.”

The care manager was concerned that Martin might be depressed and performed the PHQ-2. Indeed he screened as someone at risk for depression. Martin’s safety was a priority, and a suicide assessment was performed. Martin was not considered a suicide threat. However, Martin expressed his concern over taking antidepressants and seeking counseling with a “shrink.” He would say, “I am not a crazy!” The care manager encouraged, educated, and empowered Martin about depression. She also communicated with the treatment team regarding her suspicion of depression and a positive screening test. As she discussed this with the primary care physician, Dr. Smith indicated that Martin appeared to be non-adherent to his diabetes medication regimen as evidenced by his A1C levels. Since Dr. Smith had a good therapeutic relationship with Martin, he decided to pursue treatment for depression. Over the next eight weeks, Martin took an antidepressant and agreed to go for therapy. He experienced fear of the stigma of mental illness, had many questions about why he was experiencing depression, and even stopped the antidepressant due to the excuse that it “was not working.” Through education and motivational support by the care management team, which included the care manager, the primary care physician and the therapist, Martin continued on his medications. Interventions by the team produced adherence for depression therapy as well as for diabetes. With the care manager, Martin improved his demeanor and his A1C also improved.